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HomeMy WebLinkAboutColantuaoni Bros. Corp. - 12/31/2021=4q 5_2 5 — (00, e�'o Town of Mansfield - Board of Health Disposal Works Installer Application LICENSE NUMBER: APPLICANT: Paul Colantuonl BUSINESS NAME: Colantuoni Bros. Corp. MAIL ADDRESS: 77 Davis Ave CITY/TOWN: Norwood BUSINESS PHONE: 781-255-1001 BUSINESS FAX: 781-255-1009 STATE: MA ZIP CODE: 02062 BUSINESS CELL: 617-799-0401 E-mail: stacey@colantuonibros.com Alt E-mail: FEDERAL ID/SS NUMBER: 04-3181739 LICENSE HELD: Town Taunton LICENSE HELD: Town Dedham LICENSE HELD: Town Brookline Year Licensed 2006 Year Licensed 2008 Year Licensed 2010 ifield I have read 310 CMR 15.00, the State Environmental code; Title 5, Minimum Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health regulation titled "Minimum Standards for the Subsurface Disposal of Sanitary Sewage". I understand that deviation from them may be cause for revocation of this permit. Permit Expires December 31 st yearly. FEE: $ 100.00 SIGNATURE: Ijtu f e, Lt 41'I DATE: i! ? d. Please make appropriate changes. Sign, date, and enclose check for $100.00 payable to Town of Mansfield. Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048 TAX CERTIFICATION FORM I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. C�i(i"f%tC'fii iiu" fvF`�Cr 2civt Signature of Individual or Corporate Name By: Corpora40fficer (Mandaton/, if Applicable) 04-3181739 "Social Security No. (Voluntary) or Federal Identification Number *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Usem\sleite\Desktop\Scoa's Documents\Food Establishments- Temp\TAX CERTIFICATION FORM.doc The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:'C�1iL'iiE 1-iI1i ti k City/State/Zip: (L i`i? Ol a Phone #: � � ; i -) 15 101l 1 Are you an employer? Check the appropriate box: Business Type (required): 1.9 I am a employer with employees (full and/ S. ❑ Retail orpart-time).* 6. ❑Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑ Non-profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §1(4), and we have 10.0 Manufacturing no employees. [No workers' comp. insurance required]* I LE] Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.9 Other � `i [k ilk {W G� 1 0 r1 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #1. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: i�[i''t VFPI` {[1Ci;' 01'11 Insurer's City/State/Zip: p Policy # or Self -ins. Lic. # � 4i) { Cq Expiration Date: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofperjury that the information provided above is true and correct. Phone #: i lUL Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Phone www.mass.gov/dia A� o® CERTIFICATE OF LIABILITY INSURANCE DATE20/20IYYYY) e/zo/zo2o THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Marsh & McLennan Agency LLC 100 Front St, Ste 800 Worcester MA 01608 CONTACT Cind1/Care PHONE FAx c IN Ex 508-595-7934 Arc rvo : 866-795-8016 none ss: cind .care marshmma,com INSURERS AFFORDING COVERAGE NAIC# INSURER A: Hanover In$DranDe Company_ 22292 INSURED COLANBROSt INSURER B: Massachusetts Be Insurance Com any 22306 Colantuoni Bros, Corp. 77 Davis Avenue INSURER c :Phoenix Insurance Company 25623 INSURER D: Norwood MA 02062 INSURERE: INSURER F : Cr1VFRACFS CERTIFICATE NUMBER: 1275945883 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TR I OF INSURANCE ADDLSUBRTYPE Dean Wvn POLICY NUMBER MMID�mYY MMIDDIYYYY LIMITS B X COMMERCIAL GENERAL LIABILITY LDNA397323 8/20/2020 8/20/2021 EACH OCCURRENCE $1,000,000 CIAIMS-MADE � OCCUR PREMISES EaDA—MAGE TOEouurrrence $100,000 MED EXP (Any one person) $10,000 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $2,000,000 PRODUCTS - COMPIOP AGG $2,000,000 POLICY[X]PRO LOC JE $ OTHER: B AUTOMOBILE LIABILITY ADNA397616 8/20/2020 8/20/2021 COMBINED SINGLE LIMIT Ea accident $1,000,000 BODILY INJURY (Par person) _ $ ANY AUTO BODILY INJURY(Pereccldent) $ OWNED X SCHEDULED AUTOS ONLY AUTOS X HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY Pe�acEciR'tlen DAMAGE -- $ - - $ A X UMBRELLA LIAB X___ OCCUR UHNA397329 8/20/2020 8/20/2021 EACH OCCURRENCE $5,000,000 AGGREGATE _ $5,000,000 EXCESS LIAB CLAI MB-MADE OEO X RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNEWEXECUTIVE YIN WHNA713149 8/20/2020 8/20/2021 X IPER STATUTE OTRH- E.L. EACH ACCIDENT $500,000 E.L. DISEASE -EA EMPLOYEE $500,000 OFFICER/MEMBEREXCLUDED? (Mandatory In NH) E.L. DISEASE -POLICY LIMIT $500,000 If yes, describe under DESCRIPTION OF OPERATIONS below C Equipment Floater QT6605N94354DPHX 8/20/2020 8/20/2021 Rentell Leased From Others $205,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Job: Disposal Works Installers License The Town of Mansfield is included as an additional insured asrespects General Liability, if required by written contract, for work performed by named insured. r.FRTIFICATF Hr11 nFR CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mansfield ACCORDANCE WITH THE POLICY PROVISIONS. Board of Health AUTHORIZED REPRESENTATIVE 6 Park Row Mansfield MA 02048 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD 4 Hanover Insurance Group.. WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY 02 WORKERS COMPENSATION RENEWAL INFORMATION PAGE RENEWAL OF WHN-A713149-04 CARRIER CODE NO. 13633 Policy Number Policy Period Coverage is Provided in the Agency Code From To WHN-A713149-05 08/20/2020 08/20/2021 THE HANOVER INSURANCE COMPANY 3200769 ITEM 1. Named Insured and Address Agent Telephone: 508-852-8500 COLANTUONIBROS CORP MARSH & MCLENNAN AGENCY 77 DAVIS AVE LLC NORWOOD MA 02062 100 FRONT ST STE 800 WORCESTER, MA 01608 Federal ID No. Bureau File No. 000096629 SEE ATTACHED SCHEDULE OF ADDITIONAL LOCATIONS FOR OTHER WORKPLACES NOT SHOWN ABOVE. IF APPLICABLE SEE CONTINUATION OF NAMED INSURED SCHEDULE. ENTITY OF INSURED - CORPORATION ITEM 2. POLICY PERIOD- 08/20/20 TO 08/20/21 12:01 AM STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN. -----------------------------' ITEM 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAW AND ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE FOLLOWING STATES- MA,RI. -------------------------------------------------------------------- B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS' LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED IN ITEM 3A: BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT -------------------------------------------------------------------- C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES INSURANCE FOR THE FOL- LOWING STATES- ALL STATES EXCEPT ND,OH,WA,WY, AND THOSE STATES SPECIFICALLY NAMED IN ITEM 3A. -------------------------------------------------------------------- D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS AND SCHEDULES FORMING PART OF THIS POLICY. ------------------------------------------------------------------------------- - - ITEM 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES, CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT. ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. --------------------------------------------------------------------------- CLASSIFICATION OF OPERATIONS EST ANNUAL PREMIUM SEE ATTACHED SCHEDULE OF OPERATIONS PREMIUM DISCOUNT MINIMUM PREMIUM $750 EXPENSE CONSTANT PREMIUM FOR TERRORISM TOTAL ESTIMATED ANNUAL PREMIUM DEPOSIT PREMIUM TOTAL STATE TAXES AND ASSESSMENTS TOTAL EST ANNUAL PREMIUM INCLUDING ALL TAXES AND ASSESSMENTS --------------------------------------------------------------------- 12,366 215- 338 $179 $12,668 $12, 668 $428 $13,096 ------------ COUNTERSIGNED THIS DAY OF - - - - - - - - - - - - - - - AUTHORIZED REPRESENTATIVE BRANCH OFFICE:100 NORTH PARKWAY WORCESTER MA 01605 IF THE BILL FOR YOUR POLICY IS NOT ENCLOSED, IT WILL BE SENT TO YOU SEPARATELY. Form 331-0226 (9-03) WC000001B Date Issued: 08 21/2020 ORIGINAL/INSURED Payment Type: DIRECT BILL GROUP NAME: TARGET GROUP NUMBER: ZBG WCDECI